Here Come the Seniors

Success Key No. 3: Coordinate in the community
Improving care coordination may be essential to both meeting the needs of the elderly population and making senior health service lines profitable, but it also creates handoff and information exchange problems.

"One of the biggest challenges with the geriatric population is the handoff; the transition of care," says Barbara Looby, administrative director of senior health services at Crozer-Keystone Health System, a five-hospital system based in Drexel Hill, PA, covering 774 inpatient beds. "What happens when patients leave the inpatient hospital setting to go to an outpatient level of care, whether that's home care or another level of care such as nursing home or assisted living?"

Solutions may be easy to come by—something as simple as standardized documentation can make a big difference in improving communication and reducing medical errors. But implementing new processes across multiple settings can be a leadership headache in itself.

Several years ago Crozer-Keystone created a long-term care collaborative to gather nursing home administrators and other senior leaders in meetings five times a year to discuss how to improve the transition of care. The result has been a pilot program for two hospitals and two nursing homes to test a handoff document that is used across settings.

"We want doctor-to-doctor communication," Looby says. "There can potentially be a major gap in the transition process."

Success Key No. 4: Train physicians
Although senior health typically involves a wide range of providers and caregivers in both outpatient and inpatient settings, it centers on board-certified geriatricians. And that presents a major problem: the physician shortage.

Geriatricians are among the lowest-paid physicians, and the specialty is struggling through one of the worst physician shortages in the industry. Geriatricians average lower salaries than primary care physicians, despite completing a fellowship on top of a standard internal medicine or family practice residency.

"This is one of the great paradoxes of medicine. You have an area that's very much a shortage area, an area where the public perceives an important need, yet it's among the lowest in compensation," says Reuben. Despite being in high demand—and the specialty with the highest career satisfaction, according to some surveys—training is lagging behind thanks to bottom-of-the-barrel salaries that aren't enough to cover the growing burden of medical debt physicians bear.

Plenty of specialties are experiencing shortages these days, but none quite like geriatrics. There are currently about 7,128 geriatricians in the United States plus 1,596 geriatric psychiatrists—and these numbers are expected to increase only about 10% by 2030. The Institute of Medicine estimates the healthcare system will need about 36,000 to meet patient demand by that time.

Systems with geriatric fellowship programs have a significant advantage in being able to recruit physicians as they leave the program, Campbell says. MetroHealth Medical Center takes between two and five fellows each year and currently has about 20 geriatricians in a growth phase.

Most successful senior health programs go beyond direct geriatrics training. Senior health cuts across departments and service lines, and senior health directors may need to reach across lines to ensure that other specialists and providers are trained to treat elderly patients.

MetroHealth has received funding from the American Geriatrics Society and the Hartford Foundation for subspecialty training. "One of the things to look at is, when developing geriatric program, what are hospitals core lines of business and how does geriatrics fit into that," Campbell says. "We do specialized education of trauma surgeons, emergency medicine doctors, ophthalmologists, otolaryngologists—all of whom are involved in geriatric care."

Call it senior health or even care for active seniors. Just don't call it geriatrics.

That's a lesson Mary Wascavage learned testing messages to reach patients about Crozer-Keystone Health System's senior health services. "The definition is a moving target," says Wascavage, director of marketing for senior health services at the 774-licensed-bed system. "You can talk to one group that doesn't want to be called a senior, but when people think of geriatrics they think of older, frail people in the hospital. The lesson learned is that we tend not to use some terminology."

Crozer-Keystone's marketing tactics for reaching seniors runs the whole gamut: newspaper ads, brochures, television spots, radio advertising, health fairs. Some of the most effective efforts involve reaching out to the target community—health screenings and blood pressure assessments, for example. These efforts have the added benefit of both raising awareness and improving overall quality and health. "Dining at Dusk," for instance, is a program hosted at the system's four hospitals and other sites in the county that offers seniors low-cost meals and presentations from physicians about issues such as joint care, aging eyes, knee problems, and other health issues seniors face.

But direct-to-patient marketing for senior health really has another important audience: caregivers. Often it is a close family member who actually coordinates a senior's care, and he or she may be the real target of marketing efforts, Wascavage says.

Remote Care

Among the recommendations in the Institute of Medicine's report on Retooling for an Aging America was the adoption of activity-of-daily-living and remote technologies that "increase the efficiency and safety of care and caregiving."

These technologies are already being used in limited scope and may play a much bigger role down the road. Health First, a 850-staffed-bed system in Florida, uses telehealth technology to monitor weight, blood pressure, and oxygen saturation levels in patients with congestive heart failure, says Rosemary Laird, MD, medical director of the Health First Aging Institute. The data is transmitted to a home health service that has worked out treatment and intervention parameters with the patient's primary care physician. That saves a routine trip to the patient's home without sacrificing quality or care coordination, Laird says.

No More Payments

Beginning in October, CMS stopped paying hospitals for additional care resulting from 10 "reasonably preventable" medical errors acquired after admission. Some of the conditions on the list tend to be more common in elderly populations:

Pressure ulcers—Reduced mobility can place elderly patients at higher risk for pressure ulcers. CMS will no longer pay for Stage III or IV pressure ulcers acquired at hospitals.

Falls—Fall prevention is a major focus of senior healthcare. Fractures, dislocations, intracranial or crushing injuries, as well as burns or electric shock, have been added to the preventable errors list.

Urinary tract infections—CMS will no longer pay for infections from bladder catheters. Although they can occur in any patient, geriatric patients are more likely to be placed on a catheter immediately upon admission, making them more likely to be infected.

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